occupational therapy & lower limb amputee

Specialist Section

TraumaandOrthopaedics

Specialist Section

TraumaandOrthopaedics

Occupational therapy with peoplewho have had lower limb amputations

Evidence-based guidelines

College of Occupational Therapists

9 781905 944255

ISBN 978-1-905944-25-5

www.COT.org.ukTel: 020 7357 6480 Fax: 020 7450 2299

Availablefor Download

Download for BAOT members






2010 College of Occupational Therapists Ltd. A registeredcharity in England and Wales (No. 275119) and in Scotland (No. SCO39573) and a company registered in England (No. 1347374)

Occupational therapy with people who have had lower limb amputationsEvidence-based guidelines

This publication is an evidence-based resource to support

occupational therapists working with adults with acquired unilateral

or bilateral lower limb amputation. It provides best practice guidance

for those occupational therapists currently working in this specialism,

as well as offering a useful reference document for students and

newly qualified occupational therapists. It can also be used to inform

service users, carers and other professionals working with people

with lower limb amputation about the roles and responsibilities of the

occupational therapist in this clinical area.

Front cover photograph Mike PriorDr Gill Hicks, MBE FRSA is the founder of not-for-profit organisation M.A.D for Peace (www.madforpeace.org), and a motivational speaker, author, curator, and trustee for several cultural organisations. She was the last living survivor to be rescued from the London 7/7 bombings in 2005. Both her legs were amputated below the knee, and her injuries were so severe that she was initially not expected to live. During her rehabilitation after the bombings she was assisted by an occupational therapist who helped to get her life back. She was honoured with an MBE for her services to charity in the Queens New Years Honours List 200809 and with an Honorary Doctorate from Metropolitan University, London for her work in both the worlds of Design and Charity. Her work as a peacemaker was also acknowledged when in March 2010 she became recipient of the Iman Wa Amal Special Judges Award at the 10th Annual Muslim News Awards for Excellence. The College would like to thank Gill for her support for this publication and for agreeing to appear on the cover.

The College would like to thank Mike Prior for the use of his images for the cover.

About the publisher

www.COT.org.uk

The College of Occupational Therapists is a wholly owned

subsidiary of the British Association of Occupational Therapists

(BAOT) and operates as a registered charity. It represents the

profession nationally and internationally, and contributes widely

to policy consultations throughout the UK. The College sets the

professional and educational standards for occupational therapy,

providing leadership, guidance and information relating to research

and development, education, practice

and lifelong learning. In addition,

11 accredited specialist sections support

expert clinical practice.

1/10

Occupational therapy with people who have had lower

limb amputationEvidence-based guidelinesCollege of Occupational Therapists

LOWER LIMB.indd iLOWER LIMB.indd i 26/01/2011 14:1726/01/2011 14:17

First published in 2011by the College of Occupational Therapists106114 Borough High StreetLondon SE1 1LBwww.COT.org.uk

Copyright College of Occupational Therapists

Editors: Anita Atwal, Jane McLaughlin, Georgia SpiliotopoulouGuideline Development Group: Anita Atwal, Sandra Burke, Fiona Carnegie, Karen Cook, Jane McLaughlin, Joy Rendell, Georgia Spiliotopoulou, Anna Williams, Claire Wilson

All rights reserved, including translation. No part of this publication may be reproduced, stored in a retrieval system or transmitted, by any form or any means, electronic, mechanical, photocopying, recording, scanning or otherwise without the prior permission in writing of the College of Occupational Therapists, unless otherwise agreed or indicated. Copying is not permitted except for personal and internal use, to the extent permitted by national copyright law, or under the terms of a licence issued by the relevant national reproduction rights organisation (such as the Copyright Licensing Agency in the UK). Requests for permission for other kinds of copying, such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale, should be addressed to the Publications Offi cer at the above address.

Other enquiries about this document should be addressed to the College of Occupational Therapists Specialist Section Trauma and Orthopaedics at the above address.

While every effort has been made to ensure accuracy, the College of Occupational Therapists shall not be liable for any loss or damage either directly or indirectly resulting from the use of this publication.

ISBN 978-1-905944-25-5

Typeset by Servis Filmsetting Ltd, Stockport, CheshireDigitally printed on demand in Great Britain by the Lavenham Press, Suffolk

LOWER LIMB.indd iiLOWER LIMB.indd ii 26/01/2011 14:1726/01/2011 14:17

iiiCollege of Occupational Therapists

Contents

Acknowledgments iv Foreword by Professor Rajiv S. Hanspal, FRCP, FRCS v Foreword by Sam Gallop CBE vi

1 Rationale 11.1 The national population 1

1.2 Background 1

1.3 The development process 1

1.4 Aims of the evidence-based guidelines 2

1.5 Overview of the evidence-based guidelines document 3

2 Methodology 42.1 Evidence-based guidelines question 4

2.2 Literature search 4

2.3 Literature search fi ndings 5

2.4 Critical appraisal of articles 5

2.5 Research priorities 7

2.6 Peer reviewers and stakeholders 7

3 Summary of evidence-based recommendations 8

4 Evidence-based review and evidence-based recommendations 114.1 Functional rehabilitation 11

4.2 Environment 13

4.3 Psychology 14

4.4 Prosthetic use 16

4.5 Assessment tools and outcome measures 17

4.6 Cognition 22

4.7 Work 23

4.8 Leisure and recreation 24

Appendix 1: Guideline development group 26Appendix 2: Search strategies for literature search two 28Appendix 3: Excluded papers 31Appendix 4: How to assess the evidence (typology) 32Appendix 5: Evidence-based review table 34Appendix 6: Stakeholders 78Appendix 7: Consultation questionnaire 79Appendix 8: Glossary of terms 81References 83

LOWER LIMB.indd iiiLOWER LIMB.indd iii 26/01/2011 14:1726/01/2011 14:17

Acknowledgments With thanks to:

Brunel University, for funding this project under the Knowledge Transfer Scheme (www.brunel.ac.uk/research/rsdo/collaborative/ktp) and for the time and expert academic support provided by Dr Anita Atwal and Dr Georgia Spiliotopoulou. It is recognised that this expertise and fi nancial support have been essential to the publication of these guidelines.

The College of Occupational Therapists, particularly Julia Roberts, Anna Pettican and Mandy Sainty for their support, guidance and enthusiasm.

The College of Occupational Therapists Practice Publications Group for reviewing the document and providing valuable feedback.

The peer reviewers Dr Shelley Crawford and Dr Avril Drummond and the stakeholders (see Appendix 6).

The preliminary readers for contributing to initially screening identifi ed articles and to decide their relevance to the guidelines question.

Anne Ewing for her inspiration and motivation to begin the project.

iv Occupational therapy with people who have had lower limb amputation

LOWER LIMB.indd ivLOWER LIMB.indd iv 26/01/2011 14:1726/01/2011 14:17

vCollege of Occupational Therapists

ForewordI am delighted to see the publication of these evidence-based guidelines for occupational therapists in the rehabilitation of people with lower limb loss. The role of occupational therapists in upper limb rehabilitation and prosthetics is well recognised, but I feel that their important role in rehabilitation for lower limb loss has often been underestimated. People too often perceive rehabilitation as simply the provision of a prosthesis and gait re-education. The patient or client who has lost a lower limb has his or her whole world changed, physically and emotionally, at home, work and leisure. Holistic rehabilitation must include addressing all of these aspects. Occupational therapists often fi nd themselves addressing important needs that are essential to return the individual to as optimal a participant in the new environment as may be practical. This document should correct the misconceptions and, I hope, further improve the standards and support appropriate allocation of resources where necessary.

The fact that the recommendations are evidence-based should give greater validity to the document, especially to the scientifi cally oriented. However, in the fi eld of rehabilitation, lack of evidence should not limit the practice when trying to provide the most appropriate service to the service user. For them, personal need to fulfi l their goals remains paramount.

Standard methodology for development of guidelines has been used and the process followed has been described. The report completed a literature search and identifi ed publications specifi cally relevant to occupational therapists. It presents its fi ndings and analysis in a useful structure, including a critique of the articles reviewed, and is thus a useful summary for the professional. The evidence-based review and recommendations are presented in eight sections, analysed and supported by relevant references.

Scientifi c evidence helps guide the decision-making process between the different possible options in clinical management, but it does not replace common sense, which may override the decisions in provision of basic care and needs. Occupational therapists provide an essential component of rehabilitation for people with lower limb loss to complete a holistic package. This report will help and guide them to continue striving to provide the best for all their clients. I wish them all success.

Professor Rajiv S. Hanspal, FRCP, FRCS

Consultant in Rehabilitation Medicine, Royal National Orthopaedic Hospital

Past Chair, International Society of Prosthetics and Orthotics (ISPO), UK, and currently serving on the ISPO Protocol Committee

Past President, British Society of Rehabilitation Medicine and of the Amputee Medical Rehabilitation Society

LOWER LIMB.indd vLOWER LIMB.indd v 26/01/2011 14:1726/01/2011 14:17

vi Occupational therapy with people who have had lower limb amputation

Foreword Why do I feel privileged to be invited to write this foreword? Because as a double amputee, with third-degree burns, crush spinal fracture and other injuries, I and my family have good reasons to be grateful over many years for the caring skills of occupational therapists in helping to keep me mobile and independent.

There are many adults in the UK with lower limb amputations. Implementation of these evidence-based guidelines will signifi cantly help all of them, through the work of occupational therapists as members of multidisciplinary teams, concerned with the physical, psychological, social, spiritual and environmental needs of each individual.

There is rightly an emphasis on quality of life in which people with lower limb amputations, family members and carers are enabled to play key roles in identifying the most important activities of their lives in a spirit of real consultation. Concern with the prevention of falls will have a practical impact on health, and on keeping people safe in the community, in their homes and out of hospital. There is also a welcome understanding of the full importance of body image to the mind and the soul. Occupational therapists work in many settings, and these are all embraced.

Warm congratulations are due to the team of occupational therapists with their colleagues in Brunel University for the rigorous and high academic quality of their research and the clarity of their presentation. They have fi lled a signifi cant gap in the literature.

Occupational therapy has a real effect on the rehabilitation and quality of life for persons with lower limb amputations. These evidence-based guidelines are a further assurance of that pledge.

I conclude by wishing occupational therapists everywhere continued success and the resources they need.

Sam Gallop CBE

Advocate Associate, Parliamentary Limb Loss GroupChair, McIndoes RAF Medical Guinea Pig Club

Chair, emPOWER Charities Consortium

LOWER LIMB.indd viLOWER LIMB.indd vi 26/01/2011 14:1726/01/2011 14:17

1College of Occupational Therapists

1 Rationale1.1 The national population

The United Kingdoms (UK) National Amputee Statistical Database (NASDAB) indicates that 4957 people with lower limb amputations were referred to the UKs 43 National Health Service (NHS) prosthetic centres between April 2006 and March 2007. Seventy per cent of these amputations were due to dysvascular disease, with diabetes accounting for almost a third of all referrals. Over half of all people referred were aged over 65 years, with more than a quarter aged 75 years and over. Lower limb amputations accounted for 92 per cent of all referrals. The most common level of amputation at referral was the transtibial level (53 per cent) followed by the transfemoral level at 39 per cent (Information Services Division NHS Scotland 2009).

Although the best information available can be drawn from these fi gures, it does not show the whole picture. NASDAB represents only the population at NHS prosthetic centres and does not include data on a number of people with lower limb amputations who are referred to other settings, for example primary care trusts, intermediate care services, social services and private providers. Furthermore, these data have not been updated since April 2007, when NASDAB ceased to exist due to a lack of funding.

1.2 BackgroundOccupational therapists have a role to play at all stages of rehabilitation of people with lower limb amputations. They will be working as part of a multidisciplinary team and within various settings throughout the persons life pre-amputation, post-amputation, pre-prosthetic and post-prosthetic phases. The therapists aim is to maintain or restore the persons functional status with or without the use of a prosthesis or other equipment. Thus, there is a need to produce guidance to clearly indicate how, why and when occupational therapy can improve rehabilitation and quality of life for people with lower limb amputations. Likewise, there is a need to provide an up-to-date, evidence-based, profession-specifi c document that details stages of the occupational therapy rehabilitation process.

1.3 The development processIn December 2006 the College of Occupational Therapists Specialist Section Trauma and Orthopaedics, Lower Limb Prosthetic Occupational Therapists initiated a project stemming from a need for occupational therapy guidelines to facilitate best practice. They were later given a remit by the College to produce evidence-based national guidelines for occupational therapists working with people with lower limb amputations. Volunteers from the Lower Limb Prosthetic Occupational Therapists formed a working group made up of experts in the fi eld and specialists in lower limb rehabilitation following amputation (see Appendix 1). The group commenced the project with guidance from the College.

Since the task of producing evidence-based guidelines requires a high level of critical appraisal and research methods skills, the group sought academic assistance. From October 2008 the group accessed support from Brunel University, Centre for Professional

LOWER LIMB.indd 1LOWER LIMB.indd 1 26/01/2011 14:1726/01/2011 14:17

Rationale

2 Occupational therapy with people who have had lower limb amputation

Practice Research. As part of this collaboration a 3-day critical appraisal skills workshop was provided by Dr Anita Atwal and Dr Georgia Spiliotopoulou of Brunel University. Dr Atwal and Dr Spiliotopoulou continued to provide academic support and guidance throughout the project under the Knowledge Transfer Scheme. Brunel University is an active supporter of knowledge transfer and 15,000 was secured to fund the groups work. Knowledge transfer is a process that facilitates collaboration and active working between academics and practitioners.

1.4 Aims of the evidence-based guidelinesThe aims of the guidelines are as follows:

To provide an evidence-based resource for occupational therapists working with adults (aged 18 years and over) with acquired unilateral or bilateral lower limb amputation. This excludes children and people with congenital limb defi ciency, as the groups view was that the clinical intervention required for these groups would be signifi cantly different and warrant separate guidelines.

To facilitate best practice for occupational therapists working with people with lower limb amputation.

To provide a written reference document for use by students and newly qualifi ed occupational therapists.

To support occupational therapists and service managers in service provision and planning.

To inform service users and carers.

To inform other professionals working with people with lower limb amputation about the role and responsibilities of the occupational therapist in this clinical area.

The evidence-based guidelines are applicable to any setting where occupational therapists are working with adults who have had lower limb amputation. These settings include:

acute general hospitals (trauma and vascular services);

specialist orthopaedic hospitals or plastic surgery units (reconstructive surgery/bone tumour);

rehabilitation units (NHS and military);

intermediate and community/social services;

prosthetic and wheelchair services;

vocational rehabilitation services and work environments; and

private practice.

The categories covered were identifi ed by the expert group as being the most pertinent areas of occupational therapy intervention where evidence existed and include:

functional rehabilitation;

environment;

psychology;



Rationale

prosthetic use;

assessment tools and outcome measures;

cognition;

work; and

leisure and recreation.

1.5 Overview of the evidence-based guidelines documentThis document comprises the initial stage of a project to produce practice guidelines for occupational therapists working with adults with lower limb amputations.

In this stage, the evidence-based guidelines are presented. Evidence-based markers were developed by identifying and critiquing the existing literature; recommendations for practice were made based on this evidence. Each recommendation was based on one or more research studies, which were critiqued and for which levels of evidence and quality scores were identifi ed. Further work is now required to agree clinical guidelines based on a consensus of opinion among specialists in the fi eld of rehabilitation with people following lower limb amputation. This expert opinion will not necessarily be based on research evidence but should address many of the gaps that exist in the evidence.

Please note that the clinician using this document is ultimately responsible for the interpretation of these evidence-based guidelines in the context of their specifi c circumstances and service users. The guidelines are intended to be used alongside the therapists clinical expertise, with consideration of resources locally available. These evidence-based guidelines do not cover the requirements of the Health Professions Councils Standards of conduct, performance and ethics (HPC 2008) or the College of Occupational Therapists Code of ethics and professional conduct (COT 2010) knowledge and adherence to which is already assumed.

Note: Throughout this document people with lower limb amputation will be referred to as service users.



2 Methodology2.1 Evidence-based guidelines question

Is there evidence to support occupational therapy intervention for adults (aged 18 years and over) with lower limb amputation?

2.2 Literature searchThese evidence-based guidelines are based on literature from MEDLINE, CINAHL, OT SEEKER, OTDBASE and the Cochrane Library from 1985 to January 2009. The database search was undertaken by the two academic advisors of the working group. Two literature searches were conducted. In literature search one, occupational therapy was used as the fi rst keyword combined with other keywords, such as lower limb amputation. OTDBASE and OT SEEKER databases were searched only with the general keyword lower limb amputation, as this would be the only way to identify all related papers to occupational therapy and lower limb amputations. No research articles (qualitative or quantitative) were found that were related directly to occupational therapy or that answered the proposed question (see 2.1) from an occupational therapy perspective. Consequently, a second literature search was conducted, in which the keyword occupational therapy was removed and a more general search was performed (see Appendix 2).

The second search always used lower limb amputation as a keyword, either on its own or combined with one of the following keywords: multidisciplinary, activities of daily living, bathing, self care, domestic, quality of life, rehabilitation, driving, housing, leisure, transfers, prosthesis, outcome, cognition, falls, elderly/older people, home visits, work, phantom pain, wheelchair, occupation, social and skin. The second search had limitations, since articles without direct relevance to occupational therapy practice were also identifi ed.

The inclusion criteria for the literature search were as follows:

Quantitative, qualitative or mixed-type research.

Research published in English.

Participants had lower limb amputation.

Participants were adults aged 18 years and over.

The exclusion criteria were as follows:

Unpublished literature.

Articles not published in English.

Opinion articles.

Expert opinion or conse nsus from an expert committee (as these do not arise directly from scientifi c investigation).



Methodology

Once the literature search was completed, the evidence had to be linked directly or indirectly to occupational therapy practice within the UK. The group of experts in the fi eld embarked on determining the relevance and importance of the research evidence to their own practice.

The expert group was asked to consider the following questions:

Is there a direct reference to occupational therapy?

Is there reference to interventions/outcomes or assessments that are of relevance to occupational therapy?

Is this paper of relevance/importance to occupational therapy practice?

2.3 Literature search fi ndingsA total of 58 papers were identifi ed as being of possible relevance to occupational therapy. Of these, 29 papers were critically appraised by the group and used in the evidence-based recommendations. After reading all the other papers, the remaining 29 were fi nally excluded as they were not relevant to occupational therapy (see Appendix 3). Of the 29 excluded papers, 26 were research papers and 3 were systematic reviews; these papers have been used within the sections to set the context, but they have not been used for the evidence-based recommendations. Excluded papers were also used in the evidence sections to verify ideas and arguments linked to occupational therapy. Literature reviews were not included in the 58 papers and were excluded from the critique; however, some literature reviews were used in the background introduction of each section.

2.4 Critical appraisal of articlesProcessAll members of the critical appraisal group received three days of training from the two academic advisors before appraising the evidence. The training was based on the McMasters critical appraisal tools for both quantitative (Law et al 1998) and qualitative (Letts et al 2007) studies. Group members reviewed papers to appraise their quality and to identify their level of evidence. Each article was distributed according to its design to a member of the group who was most confi dent with the relevant research design. The appraisal of the fi rst couple of papers for each reviewer was triangulated between the reviewer and the two academic advisors of the group, who were highly experienced in paper critiquing, until the whole team was confi dent with the outcome.

Methodology for appraising the evidenceA widely used aid to critical appraisal is the hierarchy of evidence, which involves ranking a range of studies in order of decreasing internal validity; however, Petticrew and Roberts (2003) suggested that the concept of a hierarchy of evidence is diffi cult to apply in social and public health research. The hierarchy of evidence relates to quantitative research and, as suggested in The National Service Framework for Long-term Conditions (DH 2005), randomised controlled trials and other quantitative approaches are not always best to address research questions involving populations with complex needs and assessment of impact on quality of life rather than cure.


Methodology


Therefore, in order to produce evidence-based markers for occupational therapy with people with lower limb amputation, a typology was used. This was based on a mixed methodology involving:

designation of levels of evidence (adapted from the National Health and Medical Research Council (NHMRC) of Australia 1999 (see Appendix 4, Table 1));

markers related to the quality of the evidence (based on the typology used for the NSF for Long-term Conditions (DH 2005, p 88; see Appendix 4, Table 2)).

Furthermore, the research designs were categorised into primary and secondary research, and then split into quantitative, qualitative or mixed types of research (adapted from the NSF for Long-term Conditions (Department of Health 2005, p 88; see Appendix 4, Table 3)).

The designation of levels of evidence table was used as a guide to summarise study designs according to their generally perceived capacity for causing bias. This was adapted from A guide to the development, implementation and evaluation of clinical practice guidelines (NHMRC 1999). The initial designation of levels of evidence included levels I to IV. However, the group added a level V of evidence, since the original designation did not include a level for surveys, correlation studies, reliability and validity studies, outcome measures development, case studies and focus groups. Level V was used for these designs as many were identifi ed during the literature search that were of relevance to occupational therapy. From the papers used for evidence-based recommendations, 26 papers were at level V, 1 at level IV, 1 at level III-3 and 1 at III-2.

The quality assessment resulted in the assignment of a score from 0 to 10 for each paper (0 being very poor, 10 being excellent). This score related to the papers quality of research design, methodological strengths and weaknesses, integrity of conclusions, and the potential for generalisation of results. The papers used for the evidence-based recommendations scored as follows:

High quality (7/10 or greater) = 5

Medium quality (score 46/10) = 19

Poor quality (score 3/10 or less) = 5

In order for the group to make an informed decision on the quality of the paper, further guidance was provided using the McMasters guiding questions on quantitative and qualitative research.

After completion of the evidence appraisal, the fi ndings were cross-checked with the two academic advisors and compiled in an evidence-based table. This included information on the studys authors, year and location, design, participants, interventions and outcome measures used, results, limitations, relevance to occupational therapy, level of evidence and quality score (see Appendix 5).

Evidence-based recommendationsAt a further stage, the group and academic advisors met to look at the appraised research evidence. This stage involved the whole group discussing the evidence and reaching agreement in order to produce relevant evidence-based recommendations for occupational therapy practice. The group worked together to identify pertinent points from the literature and easily agreed on the statements generated. The evidence-based recommendations were categorised into the following sections: functional rehabilitation,



Methodology

environment, psychology, prosthetic use, assessment tools and outcome measures, cognition, work, and leisure and recreation.

Due to a lack of further research evidence, a number of specifi c aspects of occupational therapy management of people with lower limb amputations have not been included in this document. However, further work based on a consensus of expert opinion among professionals would help to address these areas.

2.5 Research prioritiesLarge gaps exist in this document as the research found was often of a low evidence level, or did not directly discuss the application of occupational therapy. The research found did not always demonstrate areas of occupational therapy clinical practice deemed important by the group. Current practice amongst the group can be categorised under the broad headings of pre-amputation, post-amputation/non-prosthetic rehabilitation, pre-prosthetic preparation and prosthetic rehabilitation. However, much of the evidence found did not explore the occupational therapists role in these areas. The guideline development group decided it was not appropriate to identify and underpin research priorities on the basis of the fi ndings of the evidence review; however research priorities highlighted as important to the group include: the value of occupational therapy in environmental assessment and discharge planning; the provision of wheelchairs; and integration of the prosthesis into activities of daily living. This list is by no means exhaustive.

2.6 Peer reviewers and stakeholdersThe evidence-based guidelines document was sent in draft format to peer reviewers and stakeholders (see Appendix 6). The peer reviewers were professionals working in related fi elds of occupational therapy and with experience of research and guidelines. The stakeholders were charities, user organisations or groups of other professional bodies involved with people with lower limb amputations. They were invited to comment on the quality and ease of use of the evidence-based guidelines. They gave their comments on a consultation questionnaire, which originated from the College of Occupational Therapists (see Appendix 7). The peer reviewers and stakeholders feedback and suggested amendments were integrated into the fi nal document.



3 Summary of evidence-based recommendations

Section Evidence level/quality score

Evidence-based recommendation for occupational therapy with people who have had lower limb amputation

Functional rehabilitation

V/3 1. Occupational therapists need to adhere to key milestones with respect to bed mobility and upper and lower body dressing (Ham et al 1994)

V/4 2. It is recommended that stump boards are provided for people with transtibial amputations (White 1992)

III-2/5 3. Indoor electric wheelchairs should be provided for personal independence for patients with rheumatoid arthritis (Lachman 1993)

V/4, V/6, III-3/4, V/8, V/6, IV/3

4. Occupational therapists need to identify falls risk factors and provide appropriate individual interventions in collaboration with the multidisciplinary team (Kulkarni et al 1996, Miller et al 2001, Gooday and Hunter 2004, Miller and Deathe 2004, Pauley et al 2006, Dyer et al 2008)

V/7 5. Frequency of occupational therapy sessions along with the service users physical independence, better cognition, younger age and satisfaction with the prosthesis is significantly related to prosthetic use (Bilodeau et al 2000)

Environment V/2 1. Occupational therapy with older adults who have had an amputation due to peripheral vascular disease or diabetes mellitus should enhance function through environmental modification appropriate for wheelchair use (Collin et al 1992)

Psychology V/6, V/4 1. Occupational therapists need to monitor distress for longer than the initial postoperative phase (Atherton and Robertson 2006, Hawamdeh et al 2008)

IV/4, V/4, V/6

2. Occupational therapists need to assess for anxiety throughout all episodes of care: preoperatively (Singh et al 2007, Hawamdeh et al 2008) and in the prosthetic phase (Atherton and Robertson 2006, Singh et al 2007)

V/5 3. Where appropriate, referrals should be made for psychological support for adults with lower limb amputations (Price and Fisher 2002)



Summary of evidence-based recommendations



V/3, V/3, V/5 4. Occupational therapists should consider the importance of body image during the rehabilitation process (Beekman and Axtell 1987, Breakey 1997, Price and Fisher 2002)

Prosthetic use V/5 1. Occupational therapists need to be aware of impaired hand function before prescription of liners used with lower limb prostheses (Baars et al 2008)

V/3 2. Occupational therapists need to ascertain reasons for non-prosthetic use and refer to the multidisciplinary team as appropriate (Beekman and Axtell 1987)

V/3 3. Older adults with above-knee or through-knee amputations should be provided with a wheelchair at the prosthetic and post-prosthetic stage of rehabilitation (Beekman and Axtell 1987)

Assessment tools and outcome measures

V/6 1. Occupational therapists should use the Amputee Activity Score (AAS) with lower limb prosthetic users to assess the level of activity a person achieves at discharge from prosthetic rehabilitation to review (Panesar et al 2001)

V/6 2. Occupational therapists should use the Frenchay Activities Index (FAI) to determine the level of participation in extended activities of daily living following the rehabilitation and the prosthetic phase (Miller et al 2004)

V/7 3. Occupational therapists should use the Patient Generated Index (PGI) measure to assess quality of life (QOL) outcomes in face-to-face assessment (Gallaghan and Condie 2003)

V/7 4. Occupational therapists should use the Trinity Amputation and Prosthesis Experience Amputation Scales (TAPES) to assess adjustment to lower limb prostheses (Gallagher and MacLachlan 2000)

V/6 5. Occupational therapists should use TAPES to evaluate changes in QOL during the rehabilitation process and provide a more holistic assessment (Gallagher and MacLachlan 2004)

V/8 6. Occupational therapists should use the Amputee Body Image Scale (ABIS) to determine the level of body image disturbance and consider how this may affect rehabilitation (Gallagher et al 2007)


Summary of evidence-based recommendations




V/6 7. Occupational therapists should use the Office of Population Censuses and Surveys Scale (OPCS) with lower limb prosthetic users to assess functional capacity in the community at the inpatient stage (Panesar et al 2001)

V/6, V/4 8. Occupational therapists should use the Clifton Assessment Procedures for the Elderly (CAPE) to predict mobility using a prosthesis (Hanspal and Fisher 1991, 1997)

V/4 9. Occupational therapists should use the Kendrick Object Learning Test (KOLT) to facilitate decision-making in prosthetic use (Larner et al 2003)

Cognition (same as Assessment tools and outcome measures 8 and 9)

V/6, V/4 1. Occupational therapists should use CAPE to predict mobility using a prosthesis (Hanspal and Fisher 1991, 1997)

V/4 2. Occupational therapists should use KOLT to facilitate decision-making in prosthetic use (Larner et al 2003)

Work V/5 1. Support should be provided from the multidisciplinary team regarding successful work reintegration and maintenance of the work role (Bruins et al 2003)

Leisure and recreation

V/4 1. Occupational therapists need to assess and review participation in recreational activities (Legro et al 2001)

These evidence-based recommendations are not intended to be taken in isolation. They must be considered alongside the contextual information that follows in Sections 4.14.8.

It is also strongly advisable for readers to study Appendix 5 to understand fully the outcome of the search and the overall types of evidence found.

The reader must realise that these recommendations come from evidence of varying quality and strength. Some recommendations come from single research studies or come from poorer-quality work. See Appendix 4, Table 2, to understand fully the quality of research design, methodological strengths and weaknesses, integrity of conclusions, and the potential for generalisation of results.



4 Evidence-based review and evidence-based recommendations

4.1 Functional rehabilitationIntroductionRehabilitation is a key component of nursing and allied healthcare professionals roles in most health and social care settings. Rehabilitation is a reiterative, active, educational, problem-solving process focused on a service users behaviour or disability. It includes assessment, goal-setting, intervention and evaluation (Wade and DeJong 2000). Hence, the ultimate aim of the rehabilitation is to promote reintegration into the family, home, work, leisure, social and community occupations. Occupational therapy is an integral part of this process, focusing on functional abilities and purposeful activity as part of treatment. In the case of amputation, the goal of rehabilitation following surgery is to facilitate functional independence and to assist integration back into the service users home and community.

A study by Pezzin et al (2000) suggests there is a substantial effect of inpatient rehabilitation in improving long-term physical, social and mental health outcomes of people with trauma-related amputations. Rehabilitation is of utmost importance for older adults, since functional decline may occur with older adult patients following lower limb amputation (Frykberg et al 1998). Evidence for the location of rehabilitation is mixed, and to date no UK studies have been conducted with regard to this. Klein et al (2001) compared the rehabilitation outcome of older adults with a transtibial amputation who had rehabilitation at home and as inpatients. This research found that mobility and independence outcomes were the same for both groups. However, patients who were at home had greater social support and greater satisfaction with the rehabilitation process, because they felt more involved in the planning and goal-setting.

It is important to consider mobility early on after amputation; this may be with a wheelchair. Stokes et al (2008) concluded that most therapists surveyed were following the British Association of Chartered Physiotherapists in Amputation Rehabilitation (BACPAR) guidelines (2003). BACPAR states that wheelchair mobility is the ideal, but specifi c reasons may lead therapists to teach people who have had an amputation to ambulate with aids; however, further research is needed to determine the risk that hopping poses to the contralateral foot. The lack of robust evidence means the risk of hopping cannot be quantifi ed and therefore it should be recommended with caution. Although the prevalence of skin problems of the residual limb in people who have had a lower limb amputation is mainly unknown, caring for the skin on the residuum is important as skin problems can impact on the success of prosthetic rehabilitation (Meulembelt et al 2006). Skin integrity in relation to wheelchair seating and pressure-reducing cushions also needs to be considered (Gailey and Clark 1992).

Service users may fi nd using a wheelchair preferable to using a prosthesis due to comfort, function or energy factors. When amputation is required, the appropriate level of amputation and future wheelchair use should be considered; ideally, an occupational therapist and physiotherapist should be members of the multidisciplinary team


Evidence-based review and evidence-based recommendations


(Houghton et al 1992). One study found that older adults with lower limb amputation used assistive devices with greater frequency than those with either a stroke or orthopaedic defi cit (Gitlin et al 1996). Indeed, Jones et al (1993) suggest that home modifi cations and quality of rehabilitation may be an important factor in people maintaining their independence at home, although no data to support this were offered.

EvidenceThere are currently no primary research studies that have supported the effi cacy of occupational therapy rehabilitation with people with lower limb amputations. Although there is a lack of evidence, the occupational therapy role in this area is valued and well recognised. It is important that occupational therapists promote rehabilitation to ensure people with an amputation achieve their greatest level of independence. Greive and Lankhorst (1996) concluded that in most service users, functional abilities decrease after lower limb amputation, and age seems to be a signifi cant factor related to functional outcome. One study examined the time taken to achieve specifi c functional milestones (Ham et al 1994). This study indicated that service users achieved bed mobility 12 weeks post-amputation; independence in upper body dressing within 4 weeks; and independence in lower body dressing within 5 weeks. It is important that occupational therapists enable people who have had a new amputation to achieve their greatest level of independence. The data from this study could be used to formulate an integrated care pathway that records rehabilitation milestones. The milestones could be useful for predicting the length of stay necessary in order to achieve functional independence.

A Serbian study of older people with vascular disease and unilateral amputations examined pain characteristics, functional status, social function and living conditions (urovic et al 2007). Most participants in this study achieved signifi cant functional improvement and reduction of pain, in spite of their social dysfunction, the absence of sociomedical support and inadequacy of the conditions of habitation. However, it is not clear whether even greater improvement could have resulted if occupational therapy had been included in rehabilitation.

Treatment approaches and outcomes will differ between prosthetic and non-prosthetic users, with age and functional ability before amputation being instrumental (Collin et al 1992). White (1992) found that service users reported positive benefi ts using stump boards; both therapists and users perceived stump boards as important for comfort and protecting the stump. Therapists prescribed stump boards to prevent contractures and control oedema. A study by Lachman (1993) found that people with rheumatoid arthritis and a lower limb amputation were more likely to use an electric wheelchair compared with those who had a lower limb amputation but did not have rheumatoid arthritis. Beekman and Axtell (1987) found that more than half of people who wore prostheses used their wheelchairs most of the time. These fi ndings are discussed further in Section 4.4.

It is essential that the reasons for not wearing prostheses are determined and each individuals preference is taken into account during this process. Bilodeau et al (2000) studied factors such as physical and mental health, rehabilitation, physical independence and satisfaction with the prosthesis to understand why people who had an amputation used or did not use their prosthesis. The study found that prosthetic use was signifi cantly related to the service users physical independence, better cognition, younger age and satisfaction with the prosthesis. The frequency of occupational therapy sessions was also statistically signifi cant in relation to prosthetic use.




A growing body of literature highlights the importance of falls management for people with lower limb amputations. One study found that 20 per cent of service users are likely to have a fall following amputation. Eighteen per cent of these resulted in injury, and most occurred between the times of 07:00 and 15:00 (Pauley et al 2006). Another study found that falls among service users with lower limb amputations are prevalent (58 per cent of service users with unilateral amputations and 27 per cent with bilateral amputations) (Kulkarni et al 1996). The largest proportion of falls (48 per cent) were reported as intrinsically related, 22 per cent were thought to be related to environmental reasons, 12 per cent to the prosthesis and 18 per cent to more than one factor. Gooday and Hunter (2004) found that 32 per cent had falls; these service users were signifi cantly older than those who did not fall. Miller and Deathe (2004) considered the effect of fear of falling in the prosthetic user population; they found that asking service users about fear of falling would provide a clinician with a quick indicator of whether or not the service user is experiencing reduced balance confi dence. Effective falls programmes are those that are multidisciplinary and are created to customise falls intervention for each service user deemed to be at risk of falling (Dyer et al 2008). Moreover, it is evident that people with lower limb amputation may value being taught how to get up from a fall. Kulkarni et al (1996) found that 25 per cent of those falling remembered being given instructions on how to get up from a fall.

Evidence-based recommendations

1. Occupational therapists need to adhere to key milestones with respect to bed mobility and upper and lower body dressing (Ham et al 1994).

2. It is recommended that stump boards are provided for people with transtibial amputations (White 1992).

3. Indoor electric wheelchairs should be provided for personal independence for patients with rheumatoid arthritis (Lachman 1993).

4. Occupational therapists need to identify falls risk factors and provide appropriate individual interventions in collaboration with the multidisciplinary team (Kulkarni et al 1996, Miller et al 2001, Gooday and Hunter 2004, Miller and Deathe 2004, Pauley et al 2006, Dyer et al 2008).

5. Frequency of occupational therapy sessions along with the service users physical independence, better cognition, younger age and satisfaction with the prosthesis are signifi cantly related to prosthetic use (Bilodeau et al 2000).

4.2 EnvironmentIntroductionThe environmental needs of the individual following lower limb amputation can change throughout their rehabilitation. This can vary from initial wheelchair use to independent prosthetic use. Campbell and Ridler (1996) stated that occupational therapists provide valuable insight into a service users home situation and circumstances and may predict potential problems after discharge. A study by Greive and Lankhorst (1996) found that with increasing age, functional outcomes decreased following lower limb amputation.

Diabetes neuropathy and peripheral vascular disease of the lower limbs can lead to amputation. Diabetes as a cause of amputation currently accounts for almost a third of




all referrals to prosthetics centres. Dysvascularity is the cause for 70 per cent of amputations. Over half of all people who have had an amputation referred to prosthetics centres are aged over 65 years, and more than a quarter are aged 75 years and over (Information Services Division NHS Scotland 2009). These older service users may have co-morbidities that indicate long-term use of a wheelchair.

For the individual with a lower limb amputation, providing an accessible environment is key to promoting independence at home and at work (Bruins et al 2003, Campbell and Ridler 1996, Schoppen 2001b, 2002, Van de Ven 1981). When rehabilitating people with lower limb amputations, occupational therapy may involve assessing, adapting and modifying the home or other external environments in order to facilitate participation in occupation. Pernot et al (1997) suggest that independence in activities of daily living was a key factor in predicting successful return home.

EvidenceNo primary research has been conducted by occupational therapists in this area, although Jones et al (1993) suggest that home modifi cations and quality of rehabilitation may be an important factor in people maintaining their independence at home. However, this study did not offer data to support this suggestion. Collin et al (1992) found that partial walkers had lower kitchen and domestic activity scores, which were due to a lack of environmental modifi cations for wheelchair use.

The occupational therapist needs to consider a range of factors when assessing for any environmental adaptation. Collin et al (1992) advise that for older adults following lower limb amputation, the occupational therapist should consider wheelchair use, with environmental modifi cation aimed at enhancing function.


1. Occupational therapy with older adults who have had an amputation due to peripheral vascular disease or diabetes mellitus should enhance function through environmental modifi cation appropriate for wheelchair use (Collin et al 1992).

4.3 PsychologyIntroductionPsychology is the study of the mind and soul and can involve self-concept. Self-concept can be subdivided into identity, body image, self-esteem and self-awareness. Lower limb amputation confronts the individual with numerous physical and psychosocial threats and challenges, including alterations in self-concept, physical dysfunction and pain, changes in employment/occupation status and lifestyle, and disruptions to valued activities (Rybarczyk et al 2000, Horgan and MacLachlan 2004).

Occupational therapists use psychological theories to underpin their interventions when promoting adaptation or integration for the individual. Interventions must address both the physical aspects of amputation and the psychosocial adjustment needed by the individual (Asano et al 2008). Key to understanding adjustment following lower limb amputation is the individuals experience and the inclusion of personal preference and perspectives, for example values, needs, emotional interests and motivations. Physical, environmental, social and cultural factors are also paramount (Gallagher et al 2008).




Depression and anxiety are prevalent following lower limb amputation. The need for occupational therapy management and use of occupation in addressing issues pertaining to depression and anxiety has been highlighted (Price and Fisher 2002, Hawamdeh et al 2008, Singh et al 2007).

When treating people with lower limb amputation, consideration must be given to pain, phantom pain and phantom sensation. A study by Bosmans et al (2007) demonstrates the relationship that phantom pain and sensation has upon subjective wellbeing, particularly when coupled with other factors such as medical history, social support and daily activities. However, no literature identifi es the occupational therapists role within the management of phantom pain. For this reason, the group was unable to explore the effi cacy of occupational therapy with people who experience phantom pain.

EvidenceA psychological factor specifi c to the individual following lower limb amputation is body image. Studies demonstrate how satisfaction with body image relates to an individuals anxiety, self-esteem and satisfaction with life. The therapist needs to have an understanding of this relationship throughout the rehabilitation process (Breakley 1997, Beekman and Axtell 1987, Atherton and Robertson 2006). Interventions that target appearance-related beliefs and self-consciousness are of particular relevance (Atherton and Robertson 2006). Atherton and Robertson (2006) also suggest that distress and anxiety should be monitored over a longer period of time, and not only in the initial postoperative phase following amputation.

Depression was found to be prevalent following lower limb amputation in a study by Price and Fisher (2002). They identifi ed the need for the occupational therapist to work collaboratively with the multidisciplinary team, particularly counsellors, to manage and address depression and issues surrounding body image. Along with studies by Hawamdeh et al (2008), Price and Fisher highlight the importance of occupation in decreasing anxiety and depression for the individual, both through activities of daily living and in return to work. Singh et al (2007) found that during the rehabilitation phase, where the individual was learning new skills and regaining independence, signs of anxiety and depression reduced signifi cantly. Although there are tenuous links from these studies about the value of occupational therapy, no existing research has directly studied the occupational therapists psychological management of a person following lower limb amputation; further research is needed in this area.


1. Occupational therapists need to monitor distress for longer than the initial postoperative phase (Atherton and Robertson 2006, Hawamdeh et al 2008).

2. Occupational therapists need to assess for anxiety throughout all episodes of care: preoperatively (Singh et al 2007, Hawamdeh et al 2008) and in the prosthetic phase (Atherton and Robertson 2006, Singh et al 2007).

3. Where appropriate, referrals should be made for psychological support for adults with lower limb amputations (Price and Fisher 2002).

4. Occupational therapists should consider the importance of body image during the rehabilitation process (Beekman and Axtell 1987, Breakey 1997, Price and Fisher 2002).




4.4 Prosthetic useIntroductionProsthetic rehabilitation programmes are individual to each person after lower limb amputation, but the occupational therapist should take into account the following:

level of amputation, condition of residual limb and prognosis (ability to weight-bear and balance);

co-morbidities;

cognition;

pre-amputation lifestyle and roles.

Often the overall quality of life following a lower limb amputation has been found to be lower than that in the general population, but much of this is secondary to restricted mobility (Pell et al 1993, de Godoy et al 2002). New strategies and processes need to be learnt by the service user to become mobile on their prosthesis. Achieving an independent technique donning and doffi ng the prosthesis is a signifi cant factor for the service user to succeed with prosthetic limb wearing (Baars et al 2008). Singh et al (2008) found that mobilising on a prosthesis requires considerable stamina.

A Cochrane review into prosthetic rehabilitation for older people with vascular disease following a unilateral transfemoral amputation highlighted the lack of evidence from randomised controlled studies to inform the choice of prosthetic rehabilitation (Cumming et al 2006). There is also limited research regarding the effectiveness of occupational therapy in this area. However, it is good practice that service users with a lower limb amputation should be advised on how to care for their residual limb as well as the remaining limb. Good stump care, including prevention of fl exion deformities, is an important determinant of mobility outcome (Traballesi et al 2007, Baars et al 2008). Tsai et al (2003) compared the performance and safety of walking aids in people with lower limb amputations. This study suggests that two-wheeled walking aids allow prosthetic limb wearers (especially those with transtibial amputations) to walk more quickly and with less interruption, but no less safely, compared with four-footed walking aids.

It is important to support the service user to resume previous hobbies and leisure activities. However, within occupational therapy, few studies have explored this. Hanspal and Nieveen (2002) carried out a survey to obtain a national consensus for indications and recommendations of best practice for prescription of water activity prostheses. They suggest that every limb centre should have a written procedure and agreed guidelines for prescription of water activity limbs. Each service users expectations, pre-amputation lifestyle and indication of use should be individually assessed.

EvidenceBaars et al (2008) found 70 per cent of service users with impaired hand function experienced liner-related skin problems, compared with 32 per cent of service users with normal hand function.

Beekman and Axtell (1987) found that 44 per cent of 23 service users with prostheses wore their prosthesis all day every day and used wheelchairs minimally or not at all. Over half of the service users evaluated used their wheelchairs most of the time, and 9 per cent had stopped wearing their prostheses. Over 60 per cent of the service users




reported cosmetic problems or discomfort at follow-up, and many cited this as a reason for not wearing their prosthesis.

Meulembelt et al (2006) completed a systematic review of literature of skin disorders of people who had a lower limb amputation. One article highlighted the prevalence of skin disorders in the residual limb in people with lower limb amputations. Of the 45 people in the study, 16 per cent reported skin problems. The authors suggest that skin problems can impact on prosthetic use and could impact on activities of daily living.


1. Occupational therapists need to be aware of impaired hand function prior to prescription of liners used with lower limb prostheses (Baars et al 2008).

2. Occupational therapists need to ascertain reasons for non-prosthetic use and refer to the multidisciplinary team as appropriate (Beekman and Axtell 1987).

3. Older adults with above-knee or through-knee amputations should be provided with a wheelchair at the prosthetic and post-prosthetic stages of rehabilitation (Beekman and Axtell 1987).

4.5 Assessment tools and outcome measuresIntroductionAssessment tools and outcome measures are used widely within healthcare, allowing clinicians to determine achievements in rehabilitation or areas of performance (Ryall et al 2003, Skinner and Turner-Stokes 2006). They are a tool used by healthcare professionals to appraise and monitor their service to ensure effectiveness in the service they provide (Treweek and Condie 1998, Gallaghan and Condie 2003). A study by Stineman et al (1996) commented that a standardised outcome measurement is essential in rehabilitation for:

assessing a service users rehabilitation needs;

setting client-centred goals;

evaluating the outcomes;

determining whether goals have been achieved.

Outcome measures will also assist the occupational therapist in assessing long-term needs, preparing service users for their future and managing expectations (Sansam et al 2009).

Rehabilitation of the person with lower limb amputation focuses on improving function in identifi ed areas of occupational performance and therefore the use of functional outcome measures are essential (Treweek and Condie 1998). Pernot et al (1997) suggest that individuals who had undergone a functional assessment to determine whether they were suitable for prosthetic rehabilitation had a better outcome following gait training.

To ensure that occupational therapists are using outcome measures that effectively measure a service users function, the outcome measure should have validity and reliability and be responsive to change (Panesar et al 2001). Ottenbacher et al (1996) reinforced the importance of inter-rater reliability by confi rming that any functional




outcome measure should produce consistent results across raters, and over time for therapists to measure improvement or deterioration in activities of daily living. This ensures that change detected by the outcome measurement is not due to random error.

EvidenceThe literature search highlighted the following studies assessing assessment tools and outcome measures appropriate for occupational therapists working in rehabilitation of the person who has had a lower limb amputation. Other commonly used assessment tools and outcome measures are available, such as the Canadian Occupational Performance Measure (COPM), but research evidence centred around the following tools:

Amputee Activity Score (AAS)Some of the evidence focused on activity levels of prosthetic users. A study by Panesar et al (2001) compared three measures of progress in early rehabilitation of people with lower limb amputation. The Amputee Activity Score (AAS) was directly relevant to occupational therapy. This study used a modifi ed version of the AAS; it assessed the service users:

ability to don or doff the prosthesis;

hours per day wearing the prosthesis;

use of walking aids;

amount of walking;

type of house;

ability to climb stairs;

social support at home;

caring responsibilities for someone with a disability;

participation in domestic activities of daily living; and

access to their own wheelchair and frequency of wheelchair use.

The AAS does not include a section for assessing abilities with personal activities of daily living. The study used a modifi ed AAS version as the authors deemed it necessary to include a score for service users who used their wheelchair indoors but preferred to walk outdoors. There is also a section for assessing the individuals employment status and work activities.

The AAS is a self-report tool by face-to-face interview, and the time taken to complete it is unclear. Validity and reliability of the AAS also need to be determined. A study describing the original AAS by Day (1981) stated that the validity and repeatability of the AAS were reviewed, but it is unclear from the article how these where measured.

The AAS was found to be a useful tool at discharge but more diffi cult to use at admission for rehabilitation (due to its layout) and in need of modifi cation. This study was also completed with a small sample size, and bias may have been introduced, as scores of 23 service users were based on measurements from a previous research group.

Another measure described by Panesar et al (2001) was the Offi ce of Population Censuses and Surveys Scale (OPCS). They suggested that occupational therapists could use this with lower limb prosthetic users to assess functional capacity in the community at inpatient stage.




Frenchay Activities Index (FAI)One study reviewed outcome measures assessing an individuals level of participation in instrumental activities of daily living. Miller et al (2004) reported that the Frenchay Activities Index (FAI) had been tested as valid and reliable for use with individuals following a stroke, but it had yet to be assessed as a reliable or valid tool for use with individuals with a lower limb amputation. The FAI is a 15-item self-report questionnaire assessing how often in a period of 3 months an individual has:

completed domestic activities, such as preparing meals, washing up, laundry and shopping;

continued with hobbies and using public transport.

It also assesses in the past 6 months how often an individual has:

travelled;

gardened;

participated in DIY;

read books; and

been involved in work.

For the purpose of the study, the authors decided to add three additional activities:

sport/leisure;

management of home fi nances; and

socialising with family/friends.

This made it an 18-item questionnaire and expanded the assessment components for the population of people who had an amputation.

The study assessed the reliability and validity of the FAI-15 and the FAI-18. The sample size of the study was small, but the FAI-15 and FAI-18 were found to have 4-week test-retest reliability, satisfactory internal consistency and concurrent validity; however, further tests for reliability, construct and content validity are required. The authors highlight that bias may have been introduced through the study methodology and that there was no advantage found in using the FAI-18; therefore, the FAI-15 should be used.

This measure could be used to assess an individuals level of activity in domestic, work and leisure performance components. Further assessment would be required to identify reasons for diffi culties in completion of these activities of daily living in an individual with lower limb amputation.

Patient Generated Index (PGI)Gallaghan and Condie (2003) adapted the Patient Generated Index (PGI) quality-of-life measure for use with people who had a lower limb amputation. Gallagher and Desmond (2007) and Condie et al (2006) described the PGI as a client-centred outcome measure allowing service users to identify the fi ve most important activities of their life that have been affected by amputation and its treatment. Service users rate how signifi cantly they are affected on a chosen activity on a scale of 010. They grade the importance of each activity; the higher the score, the higher their quality of life.




The PGI was found to be moderately reliable in terms of repeatability during successive follow-up interviews. Its construct validity supported a stronger relationship between mental health and quality of life than between physical health and quality of life. Therefore, this measure could be used to assess quality-of-life outcomes in this client group. The measure demonstrated practical limitations related to its format, which makes it more appropriate to be used in a face-to-face interview. It should be noted that this study used a small sample group, and validity and reliability require further testing.

Trinity Amputation and Prosthesis Experience Amputation Scales (TAPES)Gallagher and MacLachlan (2000) found that the Trinity Amputation and Prosthesis Experience Amputation Scales (TAPES) provide an initial assessment of adjustment problems. Gallagher and Desmond (2007) expanded on the TAPES, stating that it includes 9 subscales and contains 38 items. It assesses the following:

Psychological adjustment: general and social adjustment, adjustment to limitation

Activity restriction: functional, social and high activity levels

Prosthesis satisfaction: weight, function and cosmesis

Pain and other medical issues

The TAPES could identify service users who are experiencing adjustment diffi culties and assist in the development and evaluation of treatment approaches. Gallagher and MacLachlan (2004) evaluated whether TAPES subscales are associated with quality of life. The authors suggested that there is potential for clinicians to use this tool in practice to evaluate changes in an individuals quality of life throughout the rehabilitation process.

Gallagher and MacLachlan (2000) suggested that face and content validity of the tool was established, but they do not clarify how it was assessed. From both studies, it is clear that future research is required to identify the stability of the TAPES over time (test-retest reliability), responsiveness to change, and fl oor to ceiling effects to look at predictive validity. It is also acknowledged that the self-report nature of the measure could introduce bias. At present, due to the small sample sizes of both studies, the results cannot be generalised.

Amputations Body Image Scale (ABIS)Gallagher et al (2007) suggested that the Amputations Body Image Scale (ABIS) could be used in the rehabilitation of people who had an amputation to identify body image problems. The ABIS consists of a 20-item questionnaire and is scored using a 5-level ordinal scale. It assesses an individuals:

anxiety about their physical appearance in social situations or when alone;

physical appearance when wearing a prosthesis;

phantom limb pain experience;

concerns on how their limb loss affects them in daily living;

avoidance of certain situations;

viewing of their appearance, with and without the prosthesis.

Following Rasch analysis of the ABIS, the authors determined that a shortened version, the ABIS-R, would be a more valid and reliable tool. The ABIS-R was developed with 14 items and a 3-level ordinal scoring scale. This version was found to have satisfactory




internal consistency, good responsiveness to change, high separation reliability and construct validity.

The study found that the greater the levels of satisfaction with the prosthesis, the lower the levels of body image problems.

Kendrick Object Learning Test (KOLT)The search also identifi ed an outcome measure for use with individuals with cognitive impairment. Larner et al (2003) conducted a study to determine whether the Kendrick Object Learning Test (KOLT) could correctly predict whether an individual with a lower limb amputation will use a prosthesis during an inpatient rehabilitation programme. It was found to make the correct prediction in 70 per cent of cases. However, there are highlighted concerns over the reliability and validity of the assessment, and the sample size was small. The KOLT is now part of the Kendrick Scales of Cognitive Ageing (Kasca); therefore, further research would be required with the Kasca.

For further information on the KOLT, see Section 4.6.


1. Occupational therapists should use the Amputee Activity Score (AAS) with lower limb prosthetic users to assess the level of activity a person achieves at discharge from prosthetic rehabilitation to review (Panesar et al 2001).

2. Occupational therapists should use the Frenchay Activities Index to determine the level of participation in extended activities of daily living following the rehabilitation and the prosthetic phase (Miller et al 2004).

3. Occupational therapists should use the Patient Generated Index (PGI) measure to assess quality-of-life outcomes in face-to-face assessment (Gallaghan and Condie 2003).

4. Occupational therapists should use the Trinity Amputation and Prosthesis Experience Amputation Scales (TAPES) to assess adjustment to lower limb prostheses (Gallagher and MacLachlan 2000).

5. Occupational therapists should use the TAPES to evaluate changes in quality of life during the rehabilitation process and to provide a more holistic assessment (Gallagher and MacLachlan 2004).

6. Occupational therapists should use the Amputee Body Image Scale (ABIS) to determine the level of body image disturbance and consider how this may affect rehabilitation (Gallagher et al 2007).

7. Occupational therapists should use the Offi ce of Population Censuses and Surveys Scale (OPCS) with lower limb prosthetic users to assess functional capacity in the community at the inpatient stage (Panesar et al 2001).

8. Occupational therapists should use the Clifton Assessment Procedures for the Elderly (CAPE) to predict mobility using a prosthesis (Hanspal and Fisher 1991,1997).

9. Occupational therapists should use the Kendrick Object Learning Test (KOLT) to facilitate decision-making in prosthetic use (Larner et al 2003).

The studies by Hanspal and Fisher (1991, 1997) and Larner et al (2003) (points 8 and 9) also form the evidence-based recommendations for Section 4.6.




4.6 CognitionIntroductionFor successful rehabilitation with or without a prosthesis, individuals with lower limb amputation require an ability to process information, learn and apply new knowledge as they progress through the rehabilitation stages. Cognitive problems should be identifi ed at the beginning so that the team can set realistic goals and plans for discharge. Cognition has been identifi ed as a factor associated with deterioration in physical ability, an inability to complete prosthetic rehabilitation, and the ability to remain living independently (Pernot 1997, Taylor 2005, Gallagher et al 2008). Likewise, Sansam et al (2009) found that cognitive impairment is a predictor of poor prosthetic use following lower limb amputation. If cognitive dysfunction exists, such as impaired reasoning, perception, comprehension, planning, attention and memory, there will be a signifi cant impact on the persons ability to carry out functional tasks. It will also impact on all performance areas and affect successful prosthetic rehabilitation and long-term use. Gallagher et al (2008) provided an example of an activity: an individual with a transtibial amputation donning their prosthesis and then standing from a wheelchair. The individual would have to remember the following sequence: positioning the wheelchair, applying the brakes, removing wheelchair accessories, donning stump socks/liner, and applying the socket and suspension sleeve. Following this, the individual would have to check that the prosthesis was donned correctly and was comfortable before carrying out the correct transfer technique, which involves another complex sequence. There are many opportunities for an individual with cognitive impairment to experience diffi culties with the task.

EvidenceClinicians working in rehabilitation with people who have had an amputation acknowledge that a cognitive impairment can determine whether the individual will be able to use a prosthesis safely. A study by Chun-Chieh et al (2000) found that there was a statistically signifi cant relationship between impaired cognitive status and the ability to mobilise with a prosthesis. None of the service users in this study with impaired cognition was successful in mobilising with a prosthesis; however, the sample size was small, and so the results should be applied to the general population with caution. Bilodeau et al (2000) found that successful prosthetic use was found to be signifi cantly related to cognition in people with transtibial amputation. Transtibial amputation was almost signifi cantly associated with increased prosthetic use. However, as this is a correlational study (a study that describes a relationship between variables but does not identify cause and effect), further prospective studies are required to determine which variables infl uence others in this study. The relationship in this study could be due to coincidence or there could be other factors or multiple factors infl uencing the variables; this requires clarifi cation. Taylor (2005) commented that having a transfemoral amputation was a signifi cant factor in the individual who is unsuccessful in prosthetic rehabilitation.

The evidence highlighted two cognitive assessments that could be used by occupational therapists to determine level and area of defi cit. The assessments are the Kendrick Object Learning Test (KOLT) and the Clifton Assessment Procedure for the Elderly (CAPE). These assessments are also discussed in Section 4.5.

A study conducted by Larner et al (2003) found that the KOLT correctly predicted whether people with lower limb amputation will use a prosthesis during the inpatient rehabilitation programme in 70 per cent of the cases. The KOLT is a tool for assessing older peoples cognitive abilities through immediate recall of visual and auditory information, assessing speed of processing and recording information. However, there




are concerns regarding the reliability and validity of the KOLT. The KOLT is also now part of the Kendrick Scales of Cognitive Ageing (Kasca). The Kasca was based on the Kendrick battery for the detection of dementia in older service users. The Kasca test measures object recall, digit copying, reasoning and visuospatial ability, and tests cognition in individuals with neuropsychological disorder; it can also be used to screen for onset for dementia.

The CAPE is designed for use with hospital inpatients. It measures the degree of cognitive and behavioural impairment through orientation, mental abilities, psychomotor performance tests and behaviour rating scale. A study by Hanspal and Fisher (1991) suggested that the CAPE could facilitate the decision on whether the prosthesis should be prescribed. In Hanspal and Fishers 1997 study, there was a highly signifi cant positive correlation between the cognitive state of older service users and mobility achieved with prosthesis. This allows professionals to carry out assessments to ensure they make more informed decisions around prosthetic intervention and future management needs. For both studies, it should be acknowledged that a small sample size was used and regression analysis should have been used to strengthen their claims.


1. Occupational therapists should use the Clifton Assessment Procedures for the Elderly (CAPE) to predict mobility using a prosthesis (Hanspal and Fisher 1991, 1997).

2. Occupational therapists should use the Kendrick Object Learning Test (KOLT) to facilitate decision-making in prosthetic use (Larner et al 2003).

4.7 WorkIntroductionCurrent government initiatives in the UK are aimed at supporting people with and without disabilities to fi nd paid or unpaid work (Black 2008). Some studies have highlighted the perceived benefi ts of work, which include fi nancial reasons as well as social contacts with colleagues (Bruins et al 2003). Indeed, Schoppen et al (2001b) found that people who had to stop work as a result of their amputation showed a worse health experience than those people with an amputation who continued working.

There is evidence that people with lower limb amputations can have diffi culties returning to work (Schoppen et al 2001a, Burger and Marincek 2007). The proportion returning to work varied from 43.5 per cent to 100 per cent, depending on age, country and cause of amputation. Moreover, the percentage of people who returned to the same work as pre-amputation differs in various studies and depends on the type of work and the level of amputation. Factors that can delay or prevent return to work include:

problems related to the stump (Bruins et al 2003);

wearing comfort of the prosthesis (Schoppen et al 2001a);

educational level (Schoppen et al 2001a);

age at the time of amputation (Schoppen et al 2001a);

co-morbidity (Schoppen et al 2002);

workplace modifi cations (Schoppen et al 2001b, Bruins et al 2003).




Characteristics needed for successful job reintegration were perceived as being motivation, good support from employers, and better co-ordination between the multidisciplinary team, employers and companies (Bruins et al 2003). Schoppen et al (2001a) suggested that individuals with a lower limb amputation may need to change to less physically demanding roles following the amputation in order to successfully return to work. The occupational therapist should routinely ask service users about their work as part of the assessment process. The occupational therapist is well placed to address return-to-work issues, because they help people maximise employment opportunities by carrying out workplace assessments, task analysis, capacity and motivation building, and management of absence. Fisher et al (2003) found that return to work increases over time, which could suggest the need for long-term vocational rehabilitation.

EvidenceThere are no current studies to provide evidence that occupational therapy intervention assists people with lower limb amputations to return to work, although it is clear from the studies by Schoppen et al (2001a, b, 2002) and Bruins et al (2003) that occupational therapists could assist in modifying the work environment. A study by Pezzin et al (2000) suggests that following traumatic lower limb amputation, inpatient rehabilitation was positively associated with return to work and a lower likelihood of reduced hours of work.


1. Support should be provided from the multidisciplinary team regarding successful work reintegration and maintenance of the work role (Bruins et al 2003).

4.8 Leisure and recreationIntroductionThe goal of rehabilitation for people with lower limb amputations should be to facilitate a return to independence and function in all areas of their life. Legro et al (2001) found that people with an amputation participated in a wide range of recreation activities. However, Collin et al (1992) found that leisure activity scores were lowest in people with lower limb amputations who used a wheelchair. The most important constraints on participation in leisure activities for people with lower limb amputations were lack of accessibility, material considerations, functional abilities, affective constraints and social constraints (Couture et al 2009).

Hanspal and Nieveen (2002) attempted to establish national consensus for indications and recommendations for best practice for the prescription of water activity limbs. Seventy-fi ve per cent of respondents agreed to a water activity limb prescription for specifi c water activity that necessitated the use of water activity prostheses, and where risk analysis identifi ed that participation in activity presented a health and safety risk due to associated medical or physical conditions. There is evidence that participation in leisure can provide natural opportunities for social interaction and friendship, and provide a sense of identity and social inclusion (Lloyd et al 2000, Pegg and Moxham 2000, Taylor 2003). In addition, leisure participation can:

reduce psychological distress (Waters and Moore 2002);




protect against and enable individuals to manage stress (Iwasaki 2001, Kleiber et al 2002);

increase self-esteem and confi dence (Baxter et al 1995, Passmore and French 2000); and

enhance physical health (Cassidy 1996).

EvidenceNo studies were found that were related directly to occupational therapy. Further research needs to be conducted to ascertain how leisure activities are incorporated into occupational therapy programmes. Occupational therapists need to ensure that they take into account the service users individual needs and that people of a certain age may prefer more solitary leisure occupations and hence may not want to be referred for group activities. Legro et al (2001) found that people aged 60 years and over were more involved in moderate and sedentary activities than those aged 2049 years. Similar fi ndings are reported by Jones et al (1993), who found that watching television and listening to the radio are the most common activities for people with lower limb amputations (mean age 67 years, 12 years after amputation).


1. Occupational therapists need to assess and review participation in recreational activities (Legro et al 2001).



Appendix 1: Guideline development group

Expert group core membersDr Anita Atwal PhD, MSc, Dip COT (from October 2008)Director, Centre for Professional Practice Research; and Senior Lecturer in Occupational Therapy, School of Health Sciences and Social Care, Brunel University

Sandra Burke Dip COTSenior Occupational Therapist, Specialist in Prosthetics, Dorset Prosthetic Centre, Royal Bournemouth Hospital

Fiona Carnegie Dip COTSenior Occupational Therapist, Specialist in Prosthetics, Queen Marys Hospital

Karen Cook Dip COT, BA HonsSenior Occupational Therapist, Specialist in Prosthetics, Bristol Disablement Services Centre, Southmead Hospital

Jane McLaughlin (ne Hallows) BSc (Hons) (from May 2009)Senior Occupational Therapist, Specialist in Prosthetics, Manchester Disablem

Documents

occupational therapy & lower limb amputee